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Primary lymphoma of the liver
S170
Abstracts
AJG – Vol. 96, No. 9, Suppl., 2001
Conclusions: There was no statistically significant difference in the proportion of polyps overexpressing COX-2 between the placebo- and sulfonetreated patients. This suggests that NSAIDs have a chemopreventive effect independent of COX-2 activity. 533 Clinical significance of quantitative assessment of rectal anal inhibitory reflex (RAIR) in patients with constipation Xiaohong XuM.S., PJ Pasricha, M.D., S Jafri M.D. and JDZ Chen, Ph.D, FACG. Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX. The aim of this study was to evaluate the diagnostic value of quantitative assessment of RAIR in patients with constipation. Methods: 48 patients complained of pelvic floor disorders were enrolled and classified into two groups according to their primary complaints: constipation group (CO, 15F, 7M, mean age: 50 yrs) and fecal incontinence group (FI, 24F, 2M, mean age: 56yrs). An anorectal manometric probe with 4 pressure sensors staggered at a longitudinal interval of 1 cm and a balloon at the tip was inserted into the rectum with the most proximal sensor 1 cm from the anal verge. RAIR was solicited by inflating the balloon with various volumes from 10ml to 50ml. The percentage of relaxation was determined based on the rectal baseline pressure, resting sphincter pressure and sphincter pressure with the balloon distention. It is generally accepted that patients with FI do not have impaired RAIR and thus may be considered as the controls when evaluating RAIR in patients with CO. Results: 1) In patients with FI, additional inhibition achieved was only about 8% when the distention volume was increased by 70% from 30ml to 50ml (see table), suggesting that the maximum inhibition of the internal sphincter was probably reached at the distention of 50ml. 2) Percent of relaxation induced by rectal distention was significantly lower in CO than in FI at volumes from 20ml to 50ml (see table). 3) The volume of distention required to achieve a relaxation of 50% was significantly higher in patients with CO than FI (37.3⫾14.9 ml vs. 26.3⫾11.9 ml, p ⬍ 0.05). Conclusions: 1) A maximum relaxation of sphincter pressure induced by rectal distention is about 80%, suggesting that about 20% of the resting pressure measured from the manometry may be attributed to the external sphincter. 2) Patients with CO have impaired RAIR in comparison with patients with F1. 3) Quantitative assessment of RAIR is valuable in the diagnosis of patients with CO and may have pathophysiological implications.
CO FI P
10 ml
20 ml
30 ml
40 ml
50 ml
23.8 ⫾ 23.5 27.2 ⫾ 23.9 ⬎0.05
35.7 ⫾ 24.5 51.7 ⫾ 26.1 ⬍0.05
45.0 ⫾ 28.3 72.3 ⫾ 25.1 ⬍0.05
53.5 ⫾ 24.2 78.2 ⫾ 22.3 ⬍0.05
57.7 ⫾ 27.8 81.0 ⫾ 23.3 ⬍0.05
534 Screening colonoscopy prior to orthotopic liver transplantation (OLT) Mahmoud M Yousfi1, David D Douglas1, William T Savage III1, Vijayan Balan1, Hugo Vargas1, LeaAnn Nelson1, Adyr A Moss1, David C Mulligan1, Jorge Rakela1 and M. Edwyn Harrison1*. 1Transplantation Medicine, Mayo Clinic, Phoenix, AZ, United States. Purpose: Comprehensive preoperative assessment of patients undergoing OLT is crucial in selecting the most suitable candidates in an environment of limited supply of donors. The incidence of colon polyps and cancer in patients with liver cirrhosis does not differ from the general population. The aim of our study was to determine the clinical utility of screening colonoscopy in the preoperative assessment of patients undergoing OLT. Methods: We conducted a descriptive observational study on all patients undergoing preoperative evaluation for OLT in our center from 1999 – 2001. Screening colonoscopy was performed on all patients greater than 45 years old. Patients with a prior history of colorectal cancer or total colectomy were excluded. For each colonoscopy, we reviewed the quality of
preparation, completion of exam (intubation of cecum), endoscopic findings of polyps or cancer, and pathologic findings. The quality of the preparation was considered good or excellent when thorough examination of the colon was achieved; fair when small lesions might have been missed due to retained fluid or stool; and poor when examination was inadequate due to incomplete preparation. We compared the results to a control group of sequential patients undergoing colonoscopy during the same period in our center. Results: 186 patients were studied (93 in each group). The colon preparation in the group evaluated prior to OLT was reported as poor, fair, and good/excellent in 25%, 44%, and 31%, respectively, compared to 3%, 33%, and 59% in the control group, respectively. 23 patients evaluated prior to OLT had incomplete colon examination (19/23 had poor preparation) compared to none in the control group. In the OLT group, polyps were found in 25% (17% hyperplastic and 8% adenomatous), no cases of colorectal cancer were detected, and 32 patients were transplanted. None developed colorectal cancer post OLT. Conclusions: Adenomatous polyps were found in 8% of the patients screened by colonoscopy prior to OLT. Routine colorectal cancer screening guidelines apply to patients undergoing OLT evaluation. Poor preparation and incomplete colonoscopy occur more frequently in screening examinations prior to OLT than in comparably matched controls. A more vigorous colon preparation is required to screen patients effectively prior to OLT, and so to protect our scarce donor organ supply. Colonoscopy Results Poor preparation Incomplete exam
OLT group (n ⴝ 93)
Control group (n ⴝ 93)
P value
25% 25%
8% 0
⬍0.001 ⬍0.001
CLINICAL VIGNETTES 535 Primary lymphoma of the liver Emad M Abu-Hamda MD and John R Stroehlein MD*. 1 Gastroenterology, University of Texas, Houston, Health Science Center, Houston, Texas, United States. Primary lymphoma of the liver is a very rare malignancy. To date less than 100 cases have been reported in the world literature. Most patients with primary lymphoma of the liver present with a discrete liver mass or masses. We report here on an atypical presentation of an extremely rare malignancy that presented as a diffuse lesion and with fulminant hepatic failure. The case is of an 82 year old Caucasian man that was transferred to our institution with a 3 week history of jaundice, fevers and new onset confusion. A diagnosis of ascending cholangitis was made at an outside institution but the attempt at drainage by endoscopic retrograde cholanglopancreatography was unsuccessful. The ERCP was repeated in our institution and was normal as was the CT of the abdomen. Due to the patients mild pancytopenia, a bone marrow aspirate and biopsy were performed which showed a reactive lymphocytosis. Liver biopsy was subsequently performed and the histopathology was consistent with a B-cell non-Hodgkins lymphoma. The bone marrow biopsy was later read as B-cell non-Hodgkins lymphoma. Unfortunately, the patients condition deteriorated and he developed hypotension and acute renal failure. Chemotherapy was started with CHOP however his condition continued to deteriorate and the patient expired several days later. The case described in this report supports previous observations that primary lymphoma of the liver may present as diffuse organ involvement. In the few similar cases described in the literature they were rapidly fatal. This is in contrast to the majority of cases of this rare disorder that present as focal lesions in the liver and carry a more favorable prognosis.
Abstracts
AJG – Vol. 96, No. 9, Suppl., 2001
Conclusions: There was no statistically significant difference in the proportion of polyps overexpressing COX-2 between the placebo- and sulfonetreated patients. This suggests that NSAIDs have a chemopreventive effect independent of COX-2 activity. 533 Clinical significance of quantitative assessment of rectal anal inhibitory reflex (RAIR) in patients with constipation Xiaohong XuM.S., PJ Pasricha, M.D., S Jafri M.D. and JDZ Chen, Ph.D, FACG. Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX. The aim of this study was to evaluate the diagnostic value of quantitative assessment of RAIR in patients with constipation. Methods: 48 patients complained of pelvic floor disorders were enrolled and classified into two groups according to their primary complaints: constipation group (CO, 15F, 7M, mean age: 50 yrs) and fecal incontinence group (FI, 24F, 2M, mean age: 56yrs). An anorectal manometric probe with 4 pressure sensors staggered at a longitudinal interval of 1 cm and a balloon at the tip was inserted into the rectum with the most proximal sensor 1 cm from the anal verge. RAIR was solicited by inflating the balloon with various volumes from 10ml to 50ml. The percentage of relaxation was determined based on the rectal baseline pressure, resting sphincter pressure and sphincter pressure with the balloon distention. It is generally accepted that patients with FI do not have impaired RAIR and thus may be considered as the controls when evaluating RAIR in patients with CO. Results: 1) In patients with FI, additional inhibition achieved was only about 8% when the distention volume was increased by 70% from 30ml to 50ml (see table), suggesting that the maximum inhibition of the internal sphincter was probably reached at the distention of 50ml. 2) Percent of relaxation induced by rectal distention was significantly lower in CO than in FI at volumes from 20ml to 50ml (see table). 3) The volume of distention required to achieve a relaxation of 50% was significantly higher in patients with CO than FI (37.3⫾14.9 ml vs. 26.3⫾11.9 ml, p ⬍ 0.05). Conclusions: 1) A maximum relaxation of sphincter pressure induced by rectal distention is about 80%, suggesting that about 20% of the resting pressure measured from the manometry may be attributed to the external sphincter. 2) Patients with CO have impaired RAIR in comparison with patients with F1. 3) Quantitative assessment of RAIR is valuable in the diagnosis of patients with CO and may have pathophysiological implications.
CO FI P
10 ml
20 ml
30 ml
40 ml
50 ml
23.8 ⫾ 23.5 27.2 ⫾ 23.9 ⬎0.05
35.7 ⫾ 24.5 51.7 ⫾ 26.1 ⬍0.05
45.0 ⫾ 28.3 72.3 ⫾ 25.1 ⬍0.05
53.5 ⫾ 24.2 78.2 ⫾ 22.3 ⬍0.05
57.7 ⫾ 27.8 81.0 ⫾ 23.3 ⬍0.05
534 Screening colonoscopy prior to orthotopic liver transplantation (OLT) Mahmoud M Yousfi1, David D Douglas1, William T Savage III1, Vijayan Balan1, Hugo Vargas1, LeaAnn Nelson1, Adyr A Moss1, David C Mulligan1, Jorge Rakela1 and M. Edwyn Harrison1*. 1Transplantation Medicine, Mayo Clinic, Phoenix, AZ, United States. Purpose: Comprehensive preoperative assessment of patients undergoing OLT is crucial in selecting the most suitable candidates in an environment of limited supply of donors. The incidence of colon polyps and cancer in patients with liver cirrhosis does not differ from the general population. The aim of our study was to determine the clinical utility of screening colonoscopy in the preoperative assessment of patients undergoing OLT. Methods: We conducted a descriptive observational study on all patients undergoing preoperative evaluation for OLT in our center from 1999 – 2001. Screening colonoscopy was performed on all patients greater than 45 years old. Patients with a prior history of colorectal cancer or total colectomy were excluded. For each colonoscopy, we reviewed the quality of
preparation, completion of exam (intubation of cecum), endoscopic findings of polyps or cancer, and pathologic findings. The quality of the preparation was considered good or excellent when thorough examination of the colon was achieved; fair when small lesions might have been missed due to retained fluid or stool; and poor when examination was inadequate due to incomplete preparation. We compared the results to a control group of sequential patients undergoing colonoscopy during the same period in our center. Results: 186 patients were studied (93 in each group). The colon preparation in the group evaluated prior to OLT was reported as poor, fair, and good/excellent in 25%, 44%, and 31%, respectively, compared to 3%, 33%, and 59% in the control group, respectively. 23 patients evaluated prior to OLT had incomplete colon examination (19/23 had poor preparation) compared to none in the control group. In the OLT group, polyps were found in 25% (17% hyperplastic and 8% adenomatous), no cases of colorectal cancer were detected, and 32 patients were transplanted. None developed colorectal cancer post OLT. Conclusions: Adenomatous polyps were found in 8% of the patients screened by colonoscopy prior to OLT. Routine colorectal cancer screening guidelines apply to patients undergoing OLT evaluation. Poor preparation and incomplete colonoscopy occur more frequently in screening examinations prior to OLT than in comparably matched controls. A more vigorous colon preparation is required to screen patients effectively prior to OLT, and so to protect our scarce donor organ supply. Colonoscopy Results Poor preparation Incomplete exam
OLT group (n ⴝ 93)
Control group (n ⴝ 93)
P value
25% 25%
8% 0
⬍0.001 ⬍0.001
CLINICAL VIGNETTES 535 Primary lymphoma of the liver Emad M Abu-Hamda MD and John R Stroehlein MD*. 1 Gastroenterology, University of Texas, Houston, Health Science Center, Houston, Texas, United States. Primary lymphoma of the liver is a very rare malignancy. To date less than 100 cases have been reported in the world literature. Most patients with primary lymphoma of the liver present with a discrete liver mass or masses. We report here on an atypical presentation of an extremely rare malignancy that presented as a diffuse lesion and with fulminant hepatic failure. The case is of an 82 year old Caucasian man that was transferred to our institution with a 3 week history of jaundice, fevers and new onset confusion. A diagnosis of ascending cholangitis was made at an outside institution but the attempt at drainage by endoscopic retrograde cholanglopancreatography was unsuccessful. The ERCP was repeated in our institution and was normal as was the CT of the abdomen. Due to the patients mild pancytopenia, a bone marrow aspirate and biopsy were performed which showed a reactive lymphocytosis. Liver biopsy was subsequently performed and the histopathology was consistent with a B-cell non-Hodgkins lymphoma. The bone marrow biopsy was later read as B-cell non-Hodgkins lymphoma. Unfortunately, the patients condition deteriorated and he developed hypotension and acute renal failure. Chemotherapy was started with CHOP however his condition continued to deteriorate and the patient expired several days later. The case described in this report supports previous observations that primary lymphoma of the liver may present as diffuse organ involvement. In the few similar cases described in the literature they were rapidly fatal. This is in contrast to the majority of cases of this rare disorder that present as focal lesions in the liver and carry a more favorable prognosis.